SOGC joint clinical practice guideline

No. 284, December 2012

Colposcopic Management of Abnormal

Cervical Cytology and Histology
This clinical practice guideline has been prepared
by the Executive Council of the Society of Canadian
Colposcopists and approved by the Society of Obstetricians
and Gynaecologists of Canada/Society of Gynecologic
Oncology of Canada/Society of Canadian Colposcopists
Policy and Practice Guidelines Committee, the Executive
and Council of the Society of Gynecologic Oncology of
Canada and the Executive and Council of the Society of
Obstetricians and Gynaecologists of Canada.
PRINCIPAL AUTHOR
James Bentley, MB ChB, Halifax NS
Abstract
Objective: To provide a guideline for managing abnormal cytology
results after screening for cervical cancer, to clarify the appropriate
algorithms for follow-up after treatment, and to promote the best
possible care for women while ensuring efficient use of available
resources.
Outcomes: Women with abnormal cytology are at risk of developing
cervical cancer; appropriate triage and treatment will reduce
this risk. This guideline will facilitate implementation of common
standards across Canada, moving away from the current trend of
individual guidelines in each province and territory.

THE EXECUTIVE COUNCIL OF THE Evidence: Published literature was retrieved through searches of
SOCIETY OF CANADIAN COLPOSCOPISTS PubMed or Medline, CINAHL, and The Cochrane Library in October
2008 using appropriate controlled vocabulary (e.g., colposcopy,
James Bentley, MB ChB, Halifax NS cervical dysplasia) and key words (e.g., colposcopy management,
Monique Bertrand, MD, London ON CIN, AGC, cervical dysplasia, LEEP, LLETZ, HPV testing, cervical
dysplasia triage). Results were restricted to systematic reviews,
Lizabeth Brydon, MD, Regina SK
randomized control trials/controlled clinical trials, and observational
Hlne Gagn, MD, Ottawa ON studies. There were no date or language restrictions. Searches were
Brian Hauck, MD, Calgary AB updated on a regular basis and incorporated in the guideline to July
2012. Grey (unpublished) literature was identified through searching
Marie-Hlne Mayrand, MD, Montreal QC the websites of health technology assessment and health technology
Susan McFaul, MD, Ottawa ON assessment-related agencies, clinical practice guideline collections,
and national and international medical specialty societies.
Patti Power, MD, St. Johns NL
Expert opinion from published peer-reviewed literature and
Alexandra Schepansky, MD, Edmonton AB
evidence from clinical trials is summarized. Consensus opinion is
Marina Straszak-Suri, MD, Ottawa ON outlined when evidence is insufficient.
SPECIAL CONTRIBUTORS Values: The quality of the evidence is rated using the criteria described
Terry Colgan, MD, Toronto ON by the Canadian Task Force on Preventive Health
Care (Table 1).
Laurette Geldenhuys, MD, Halifax NS
Validation: This guideline has been reviewed for accuracy from content
Mark Heywood, MD, Vancouver BC
experts in cytology, pathology, and cervical screening programs.
Roberta Howlett, PhD, St. Thomas ON Guideline content was also compared with similar documents from
Linda Kapusta, MD, Mississauga ON other organizations including the American Society for Colposcopy and
Cervical Pathology, the British Society for Colposcopy and Cervical
Rachel Kupets, MD, Toronto ON Pathology, and the European Cancer Network.
Joan Murphy, MD, Toronto ON
Jill Nation, MD, Calgary AB
J Obstet Gynaecol Can 2012;34(12):11881202
Vyta Senikas, MD, Ottawa ON
Michael Shier, MD, Toronto ON
Key Words: Cervical cytology, cervical cancer, colposcopy,
Disclosure statements have been received from all authors. treatment, follow-up, abnormalities, guidelines

This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information
should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate
amendments to these opinions. They should be well documented if modified at the local level. None of these contents may be
reproduced in any form without prior written permission of the SOGC.

1188 l DECEMBER JOGC DCEMBRE 2012

 Colposcopic Management of Abnormal Cervical Cytology and Histology
Table 1. Key to evidence statements and grading of recommendations, using the ranking of the Canadian Task Force
on Preventive Health Care
Quality of evidence assessment*
I: Evidence obtained from at least one properly randomized
controlled trial
II-1: Evidence from well-designed controlled trials without
randomization
II-2: Evidence from well-designed cohort (prospective or
retrospective) or casecontrol studies, preferably from
more than one centre or research group
II-3: Evidence obtained from comparisons between times or
places with or without the intervention. Dramatic results in
uncontrolled experiments (such as the results of treatment with
penicillin in the 1940s) could also be included in this category
III: Opinions of respected authorities, based on clinical experience,
descriptive studies, or reports of expert committees
*The quality of evidence reported in these guidelines has been adapted from The Evaluation of Evidence criteria described in the Canadian Task Force on
Preventive Health Care.95
Recommendations included in these guidelines have been adapted from the Classification of Recommendations criteria described in the Canadian Task Force
on Preventive Health Care.95
Recommendations
Managing Cytological Abnormalities
The age of the patient may affect management and where pertinent
will be identified in the recommendation.
The Colposcopy Examination
01. Colposcopic findings are best described according to the
terminology defined by the International Federation for Cervical
Pathology and Colposcopy. (III-C)
ABBREVIATIONS
AC adenocarcinoma
AGC-N atypical glandular cells-favour neoplasia
AGC-NOS atypical glandular cells-not otherwise specified
AGUS atypical glandular cells of undetermined significance
AIS Adenocarcinoma in situ
ALTS ASCUS/LSIL Triage Study for Cervical Cancer
ASC-H atypical squamous cells-cannot exclude
high-grade squamous intraepithelial lesion
ASCUS atypical squamous cells of undetermined
significance
CIN cervical intraepithelial neoplasia
ECC endocervical curettage
HPV human papillomavirus
HR-HPV high-risk HPV
HSIL high-grade squamous intraepithelial lesion
LEEP/ LLETZ loop electrosurgical excision procedure/large loop
excision of the transformation zone
LSIL low-grade squamous intraepithelial lesion
Pap smear Papanicolaou smear
SCC squamous cell carcinoma
TZ transformation zone
Classification of recommendations
A. There is good evidence to recommend the clinical preventive action
B. There is fair evidence to recommend the clinical preventive action
C. The existing evidence is conflicting and does not allow to make a
recommendation for or against use of the clinical preventive action;
however, other factors may influence decision-making
D. There is fair evidence to recommend against the clinical preventive action
E. There is good evidence to recommend against the clinical preventive
action
L. There is insufficient evidence (in quantity or quality) to make
a recommendation; however, other factors may influence
decision-making
02. At colposcopy, 2 or more biopsy specimens should be
taken. (I-A)
03. An endocervical curettage should be performed when the
transformation zone is not visible in women with an AGC
Pap smear and in women over 45 years old with high-grade
cytology. (II-2B)
04. Routine HR-HPV testing for all colposcopy referrals is
discouraged. (III-C)
Managing Women With ASCUS or LSIL
on Referral for Colposcopy
05. A woman with persistent ASCUS/LSIL or ASCUS HR-HPV
positive cytology should be referred for colposcopy as directed
by provincial/territorial guidelines. (III-A)
06. A colposcopically identified lesion should be biopsied. (III-C)
07. If no lesion is identified, biopsies of the transformation zone
should be considered. (III-C)
Managing ASC-H
08. A woman with an ASC-H Pap smear should have colposcopy to
rule out CIN 2 or 3 and/or cancer. (II-2A)
09. Biopsies should be performed on any identifiable lesions at
colposcopy. (II-2A)
10. With an ASC- H Pap smear, the finding of negative colposcopy
does not automatically warrant a diagnostic excisional
procedure. (III-E)
Managing HSIL
11. All women with an HSIL test result should have
colposcopy. (II-2A)
12. In the absence of an identifiable lesion at colposcopy, whether
satisfactory or unsatisfactory, an endocervical curettage and
directed biopsies should be performed. (III-B)
13. In women with HSIL, when the transformation zone is not seen
in its entirety and endocervical curettage and/or biopsy results
DECEMBER JOGC DCEMBRE 2012 l 1189
SOGC joint clinical practice guideline
are negative, a diagnostic excisional procedure should be
considered. (III-B)
Managing Atypical Glandular Cytology
(AGC-NOS, AGC-N, AIS)
14. The finding of an AGC Pap smear warrants colposcopy. (II-2A)
15. All women with an AGC Pap smear should have an endocervical
curettage. Women over 35 years of age or with a history of
abnormal bleeding should have endometrial sampling. (II-2A)
16. Women with an AGC-N Pap smear without an identifiable
lesion at colposcopy should undergo a diagnostic excisional
procedure. (II-2A)
Managing Squamous Cell Carcinoma and
Adenocarcinoma on Cytology
17. Women with a cytologic diagnosis suggestive of carcinoma,
with or without a visible lesion, should have colposcopy and
appropriate biopsies. (III-A)
Managing the Patient With Abnormal HPV
Test and Normal Cytology
18. Women less than 30 years old should not have HR-HPV testing
done as a screen with cytology. (II-2E)
19. Women less than 30 years old who are HR-HPV positive and
have normal cytology should be followed as per provincial/
territorial guidelines; colposcopy is not required. (III-B)
20. Women 30 years old and over who test positive for HR-HPV
and have negative cytology should have HR-HPV and cytology
testing repeated at 12 months. Persistent positive HR-HPV tests
warrant colposcopy. (I-A)
Managing Abnormal Cytology in Pregnancy
21. Women with an ASC-US or LSIL test result during pregnancy should
have repeat cytology testing at 3 months post pregnancy. (III-B)
22. Pregnant women with HSIL, ASC-H, or AGC should be referred
for colposcopy within 4 weeks. (III-B)
23. Endocervical curettage should not be performed during
pregnancy. (III-D)
Managing Abnormal Cytology in
Women Less Than 21 Years Old
24. Cytological screening should not be initiated in women less than
21 years old. (II-2E)
25. If screening is done in a woman less than 21 years old, and an
ASC-US or LSIL result is reported, cytology should be repeated
only per provincial or territorial guidelines. (III-B)
26. A woman less than 21 years old who has cytology results of
ASC-H, HSIL, and AGC should be referred for colposcopy. (III-B)
Managing Histological Abnormalities
Managing CIN 1
27. The preferred option for biopsy-proven CIN 1 is observation
with repeat assessment at 12 months with cytology testing.
(Colposcopy at 12 months is an acceptable option.)
Management should be according to the cytology
result. (II-1B)
28. In the case of a patient with biopsy-proven CIN 1 after HSIL
or AGC, cytology and histology should be reviewed, where
available. If a discrepancy remains, then an excisional biopsy
may be considered. (III-B)
1190 l DECEMBER JOGC DCEMBRE 2012
Managing CIN 2 or 3 in Women
Aged 25 Years and Over
29. CIN 2 or 3 should be treated. Excisional procedures are
preferred for CIN 3. (II-1A)
30. Women who have positive margins should have follow-up with
colposcopy and directed biopsies and/or endocervical curettage.
Treatment for recurrent or persistent CIN 2 or 3 should be by
excision. (II-1B)
Managing CIN 2 or 3 in Women Less Than 25 Years Old
31. The pathologist should be asked to clarify whether the lesion is
CIN 2 or CIN 3. (III-B)
32. CIN 2 in women less than 25 years old should be
observed with colposcopy at 6-month intervals for up to
24 months before treatment is considered. (II-2B)
33. CIN 3 in women less than 25 years old should be
treated. (III-B)
Managing Adenocarcinoma in Situ
34. If AIS is diagnosed, treatment needs to be a diagnostic
excisional procedure, or type 3 transformation zone
excision. (II-2A)
35. If margins are positive after diagnostic excisional procedure,
a second excisional procedure should be performed. (II-2A)
36. If after treatment for AIS a woman has finished childbearing,
a hysterectomy should be considered. (III-B)
37. If AIS is diagnosed after LEEP is performed for CIN in a woman
who has not completed her family and margins are negative,
it is unnecessary to perform a further diagnostic excisional
procedure. (II-2E)
Managing Histological Abnormalities During Pregnancy
38. If CIN 2 or CIN 3 is suspected or diagnosed during pregnancy,
repeat colposcopy and treatment should be delayed until 8 to 12
weeks after delivery. (II-2A)
Follow-up Post Treatment for CIN 2 or 3
Either option is acceptable:
39. Women should be followed with cytology testing and colposcopy
at 6-month intervals for 2 visits. If both cytology and any biopsies
are negative, they will then return to screening per provincial/
territorial guidelines. (II-2B)
40. HPV testing at 6 months combined with cytology testing is
acceptable. If both are negative, women may return to screening
per provincial/territorial guidelines. (II-2B)
Managing Histological Abnormalities in Women at High Risk
41. Immunocompromised women do not require screening
colposcopy. (II-2D)
Wait Times for Colposcopy
42. Women with ASC-H or AGC should be seen in a colposcopy
clinic within 6 weeks of referral. (III-C)
43. Women with HSIL should ideally be seen in a colposcopy
clinic within 4 weeks of referral. (III-C)
44. Women with a Pap smear suggestive of carcinoma
should be seen in a colposcopy clinic within 2 weeks of
referral. (III-C)
45. All other women with abnormal results should be seen in a
colposcopy clinic within 12 weeks of referral. (III-C)
 Colposcopic Management of Abnormal Cervical Cytology and Histology
INTRODUCTION
O ver the last 30 years cervical cancer morbidity and
mortality rates have dropped significantly in Canada,
from approximately 30 per 100000 to 7 per 100000
women.1 This change has been widely attributed to the
availability of cervical screening via cytologic sampling.2
Colposcopy has evolved to become a tool for evaluating
those with abnormal cytology and obtaining histological
samples by biopsy. Treatment of lesions can then be
performed, usually preserving fertility and making major
surgery unneccesary.3 Numerous jurisdictions have
developed guidelines48 for colposcopy, and these have
been reviewed in developing this document.
Cervical cancer screening is organized within each
province and territory in Canada. Screening programs issue
screening and follow-up recommendations for abnormal
screening results, including referral for colposcopy. The
diversity and status of cervical screening in Canada has
been summarized elsewhere.9
A review of the recommended age for initial screening
was initiated by the American Society of Colposcopy
and Cervical Pathology, which in June 2009 convened a
consensus practice improvement conference that included
representatives from the United States and Canada.
Outcomes from this meeting included a recommendation
to start screening at age 21.10 This recommendation has
been incorporated into new guidelines from Quebec,11
Alberta,12 and Ontario.13
Canadian colposcopic practice is unique in several ways.
Colposcopy is performed predominantly by gynaecologists
in both hospital clinics and private offices. Access to HPV
testing is currently limited outside teaching hospitals.
The primary aim of these guidelines is to standardize the
colposcopic care provided for women in Canada.
COLPOSCOPIC MANAGEMENT OF
CYTOLOGICAL ABNORMALITIES
Screening and colposcopy recommendations vary across
provinces and territories and have been documented
elsewhere.9 Current guidelines for colposcopic referrals
can be summarized as follows: referral for colposcopy is
recommended for persistent ASCUS, persistent or incident
LSIL, ASC-H, HSIL, and AGC, as well as for Pap smears
that suggest squamous or glandular carcinoma. HPV
testing is not widely available; however, when reflex HPV
testing shows the presence of oncogenic or HR-HPV with
ASCUS cytology, referral for colposcopy is recommended.
THE COLPOSCOPY EXAMINATION
Colposcopy is the examination of the lower genital tract
and cervix using magnification from a colposcope with
a good light source. The squamocolumnar junction and
transformation zone should be identified; this determines
whether the examination is satisfactory or not. Acetic acid is
then used to assess the size, shape, margin, and location of
any neoplastic lesion. These findings can then be described
according to the new nomenclature of the International
Federation for Cervical Pathology and Colposcopy.14
When any lesion is identified, recent evidence supports
the practice of taking at least 2 biopsy specimens to
improve the accuracy of colposcopy. A biopsy should be
performed and specimens taken of the most severe area
found on colposcopic examination to confirm or rule out
malignant lesions.15,16 Analysis of the ALTS data showed
that taking 2 biopsies for a low-grade cytology referral at
initial colposcopy improved the sensitivity (to detect CIN 2
or greater) to 81.8%, compared with 68.3% with 1 biopsy.15
A recent review of the utility of endocervical curettage was
published using data from Calgary. Using data from over
13000 examinations, the authors showed that 99 ECC
specimens had to be taken to detect 1 additional case of
CIN 2 or higher grade lesion. The largest benefit was in older
women referred after high-grade cytology.17 An ECC should
thus be performed in the case of unsatisfactory colposcopy,
an AGC smear, and in older women with high-grade cytology.
A low threshold is recommended for undertaking a biopsy.
If any lesion is seen, biopsy should be completed. If only
metaplasia is in question, a biopsy should be considered.
Unless dictated by the appropriate algorithm, there is no
role for routine HR-HPV testing in the colposcopy clinic.
Clinical Tip: HPV Vaccination
A womans visit to the colposcopy clinic is an opportune time
to discuss HPV vaccination with her. Even if she has not been
previously vaccinated a woman may benefit from vaccination to
prevent new HPV infections.
Recommendations
1. Colposcopic findings are best described
according to the terminology defined by the
International Federation for Cervical Pathology
and Colposcopy. (III-C)
2. At colposcopy, 2 or more biopsy specimens should
be taken. (I-A)
3. An endocervical curettage should be performed
when the transformation zone is not visible in
women with an AGC Pap smear and in women
over 45 years old with high-grade cytology. (II-2B)
DECEMBER JOGC DCEMBRE 2012 l 1191
SOGC joint clinical practice guideline
4. Routine HR-HPV testing for all colposcopy
referrals is discouraged. (III-C)
MANAGING WOMEN WITH ASCUS OR LSIL
ON REFERRAL FOR COLPOSCOPY
Management of low-grade abnormalities remains
controversial. A large randomized trial in the United States
concluded that women with LSIL cytology results were
best managed by immediate referral for colposcopy; it was
noted that 83% were positive for HR-HPV and thus HPV
triage would not be effective.18 The same study reported
that women with ASCUS results, but negative for HR-
HPV, could safely be triaged away from colposcopy.18 This
approach requires access to reflex HPV testing, which
unfortunately is not widely available in Canada. A recent
multicentre study in the United Kingdom evaluated the
management of similar low-grade cytology. The study
concluded that there was no clear benefit of a policy of
immediate colposcopy as although it detects more cervical
intraepithelial neoplasia grade II or more severe disease,
it leads to a large number of referrals with no high grade
cervical intraepithelial neoplasia [and] overtreatment with
associated after effects in young women.19
With low-grade lesions, colposcopy is done to rule out
potentially premalignant changes i.e., CIN 2 or 3; if these
are detected, management is undertaken according to the
appropriate protocol. A meta-analysis reported CIN 2+
rates of 10% and CIN 3+ of 6% with an ASCUS referral.20,21
With an LSIL referral, the rates of CIN 2+ are 17% and
CIN 3+ 12%.22,23 If CIN 1 is the highest grade identified
at colposcopy, conservative management is recommended.
If no lesion is identified at colposcopy, a random biopsy
at the transformation zone should be considered. As
per consensus opinion, if no dysplasia is identified at
colposcopy, annual screening with the referring health care
provider is recommended until 3 negative Pap smears have
been reported. If all cytology is negative, women may then
be followed every 2 to 3 years, consistent with provincial/
territorial guidelines.
Recommendations
5. A woman with persistent ASCUS/LSIL or ASCUS
HR-HPV positive cytology should be referred for
colposcopy as directed by provincial/territorial
guidelines. (III-A)
6. A colposcopically identified lesion should be
biopsied. (III-C)
7. If no lesion is identified, biopsies of the
transformation zone should be considered. (III-C)
1192 l DECEMBER JOGC DCEMBRE 2012
MANAGING ASC-H
With an ASC-H result on the Pap smear, significant
pathology is typically found in the majority of cases.
In a study of 517 cases from Edmonton, Alberta, CIN
2 or greater was detected in 70% of cases. Most cases
were CIN 2; however, invasive carcinoma was reported
in 2.9% of cases and AIS in 1.7%.24 A similar Ontario
study showed CIN 2 or greater in 59.4% of cases with
a stronger correlation in women under 40 years of age.25
All women with ASC-H should have colposcopy to rule
out significant pathology. If colposcopy is negative,
recommendations include repeat colposcopy, repeat
cytology and, ideally, HR-HPV testing twice, at 6-month
intervals, to ensure a significant lesion is not missed. If
these repeat tests are negative, women may return to
regular screening, as per provincial/territorial protocol.
The finding of ASC-H with negative colposcopy does
not warrant a cone biopsy or excisional procedure for
diagnostic purposes.
Recommendations
8. A woman with an ASC-H Pap smear should
have colposcopy to rule out CIN 2 or 3 and/or
cancer. (II-2A)
9. Biopsies should be performed on any identifiable
lesions at colposcopy. (II-2A)
10. With an ASC-H Pap smear, the finding of
negative colposcopy does not automatically
warrant a diagnostic excisional procedure. (III-E)
MANAGING HSIL
The risk of a significant lesion is high with HSIL cytology.
Studies have shown CIN 2 or greater in 53% to 66% of
cases in which colposcopic biopsies are undertaken, and up
to 90% if an immediate LEEP is performed.26,27 Because
of this high rate of significant high-grade histology, all
women with an HSIL result should have colposcopy. A
visual assessment and LEEP approach may be appropriate
in some circumstances, but a colposcopically directed
biopsy and tailored treatment is preferred.
If a lesion is not detected at colposcopy and colposcopy
is not satisfactory, then a diagnostic excisional
procedure should be done. This can be achieved with
a cone biopsy, or LEEP using a large loop, or a second
endocervical pass. However, if no lesion was detected
and colposcopy was satisfactory, combined colposcopy
and cytology is appropriate at 6-month intervals for
2 visits. This situation is rare. For women who have
finished childbearing, a diagnostic excisional procedure
should be considered.
 Colposcopic Management of Abnormal Cervical Cytology and Histology
Recommendations
11. All women with an HSIL test result should have
colposcopy. (II-2A)
12. In the absence of an identifiable lesion at
colposcopy, whether satisfactory or unsatisfactory,
an endocervical curettage and directed biopsies
should be performed. (III-B)
13. In women with HSIL, when the transformation
zone is not seen in its entirety and endocervical
curettage and/or biopsy results are negative,
a diagnostic excisional procedure should be
considered. (III-B)
MANAGING ATYPICAL GLANDULAR
CYTOLOGY (AGC-NOS, AGC-N, AIS)
The finding of AGC-NOS, AGC-N, or AIS always
warrants prompt referral for colposcopy in the absence
of other symptomatology. Neoplastic lesions found
in areas other than the cervix, including endometrium,
ovary, and fallopian tube, have been identified with AGC
cytology.2830 In a Canadian report, 456 cases of AGC or
AGUS were identified from a database of over 1 million
Pap smears (0.043%).29 On final histologic follow-up, 7%
were found to have CIN 1, 36% were found to have CIN
2 or 3, AIS was identified in 20%, carcinoma of the cervix
in 9%, and endometrial pathology in 29%, including
carcinoma of the endometrium in 10%. It should be
noted that CIN is consistently the most frequent finding
across many studies.28-31 This high rate of pathology
precludes any attempt to triage using repeat cytology or
HPV testing.
The diagnosis of AGC-N is associated with higher rates of
abnormalities and thus, in the absence of an abnormality
found by colposcopy, a diagnostic excisional procedure
should be performed.32,33 These procedures includes cold
knife cone biopsy and laser cone biopsy and may include
LEEP if the specimen is of sufficient size. A hysterectomy
is not considered a diagnostic excisional procedure.
Endocervical curettage should be done in all women, and
endometrial sampling should be performed in women
who are over 35 years or who have a history of abnormal
bleeding, including anovulation.
However, with AGC-NOS cytology and the absence of
an identified lesion, women are still at risk of developing
a lesion. In this situation, follow-up assessment every
6 months for 2 years includes repeat cytology testing,
colposcopy, and ECC. If HR-HPV testing is available
and was done at the initial colposcopy visit, women who
test negative for HR-HPV may have repeat assessment
with colposcopy, cytology testing, ECC, and HR-HPV
testing at 12 months. If a lesion is identified, treatment
is in accordance with the guideline specific to the type
of lesion. If a carcinoma is identified, referral should
be made to a gynaecologic oncologist. If all follow-up
is negative after 2 years, routine cytologic testing may be
resumed.
Recommendations
14. The finding of an AGC Pap smear warrants
colposcopy. (II-2A)
15. All women with an AGC Pap smear should have
an endocervical curettage. Women over 35 years of
age or with a history of abnormal bleeding should
have endometrial sampling. (II-2A)
16. Women with an AGC-N Pap smear without an
identifiable lesion at colposcopy should undergo a
diagnostic excisional procedure. (II-2A)
MANAGING SQUAMOUS CELL CARCINOMA
AND ADENOCARCINOMA ON CYTOLOGY
Women should be referred promptly for colposcopy if
their Pap smear is suggestive of carcinoma, with or without
a visible lesion. Assessment should include colposcopy
and directed biopsy, and ECC should be considered. If no
abnormality is detected, a diagnostic excisional procedure
is recommended to rule out occult carcinoma. Endometrial
biopsy should also be contemplated in the workup of
women with adenocarcinoma found by Pap smear.
Recommendation
17. Women with a cytologic diagnosis suggestive of
carcinoma, with or without a visible lesion, should
have colposcopy and appropriate biopsies. (III-A)
MANAGING THE PATIENT WITH ABNORMAL
HPV TEST AND NORMAL CYTOLOGY
Women with ASCUS and positive reflex HR-HPV should
be referred for colposcopy. However, no provincial
guidelines address management of negative cytology
findings combined with a positive HR-HPV result.
Women with negative cytology and positive HPV results
should have both tests repeated with their primary health
care provider after 12 months.34,35 If both tests are negative
at 12 months, women should return to being screened
according to provincial/territorial guidelines. Women with
a cytological abnormality should be managed according to
the cytological diagnosis. If there is persistent HR-HPV on
2 tests 1 year apart, referral for colposcopy is recommended
to rule out the possibility of a high-grade lesion.
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SOGC joint clinical practice guideline
Recommendations
18. Women less than 30 years old should not have HR-
HPV testing done as a screen with cytology. (II-2E)
19. Women less than 30 years old who are HR-HPV
positive and have normal cytology should be
followed as per provincial/territorial guidelines;
colposcopy is not required. (III-B)
20. Women 30 years old and over who test positive
for HR-HPV and have negative cytology should
have HR-HPV and cytology testing repeated at 12
months. Persistent positive HR-HPV tests warrant
colposcopy. (I-A)
MANAGING ABNORMAL
CYTOLOGY IN PREGNANCY
The indications for colposcopy in pregnant women are
essentially the same as in non-pregnant women. If a low-
grade lesion (ASCUS or LSIL) is found during pregnancy,
the Pap smear should be repeated 3 months postpartum.
This practice is safe as the rate of cancer in this group is
very low.36 If HSIL, ASC-H, or AGC is found, prompt
evaluation with colposcopy is essential. If colposcopy is
unsatisfactory in the first trimester, it should be repeated
after 20 weeks gestation when, because of the physiological
changes, the cervix everts itself and the squamocolumnar
junction may become visible.
If CIN 3 or carcinoma is suspected, biopsy is recommended.
There is evidence that biopsy in pregnancy is not harmful.37
Women with high-grade dysplasia in pregnancy should be
seen by an experienced colposcopist.
Recommendations
21. Women with an ASC-US or LSIL test result during
pregnancy should have repeat cytology testing at
3 months post pregnancy. (III-B)
22. Pregnant women with HSIL, ASC-H, or
AGC should be referred for colposcopy within
4 weeks. (III-B)
23. Endocervical curettage should not be performed
during pregnancy. (III-D)
MANAGING ABNORMAL CYTOLOGY IN THE
WOMAN LESS THAN 21 YEARS OLD
There is little evidence that screening by cytology testing in
adolescents (<21 years old) is beneficial. The incidence of
cervical cancer is very low. The Surveillance, Epidemiology,
and End Results data from the United States showed
a rate of 0.1/100000 in women 15 to 19 years old and
1.6/100000 in women 20 to 24 years old, compared with
15.5/100000 in women 40 to 45 years old.38 Although
1194 l DECEMBER JOGC DCEMBRE 2012
HPV infection and low-grade abnormalities found by
Pap smears are common in this age group, most of these
infections and related cytological changes will resolve
without intervention.39,40 Screening is invasive and can
have adverse psychological sequelae, especially if it leads
to colposcopy referral.10,41
If this screening leads to treatment by LEEP, this can later
be associated with a slightly increased risk of premature
rupture of membranes and preterm delivery.42,43 HPV
vaccination has recently been instituted in Canada, and the
high efficacy against HPV 16 and 18 should result in fewer
high-grade lesions needing treatment.44-48 The American
Congress of Obstetricians and Gynecologists and several
Canadian organizations have therefore recommended that
screening begin at 21 years of age.1113,4952
In women less than 21 years, if a Pap smear has been done
and abnormalities are detected at screening, management
should be conservative to prevent harm. Low-grade
changes, i.e., ASC-US and LSIL, regress in up to 93%
of cases with conservative management. Thus women
less than 21 years with ASC-US and LSIL results should
have cytology testing repeated in 1 year, with referral to
colposcopy only if abnormalities persist for 24 months.10
Women less than 21 years with ASC-H, HSIL, or AGC
results should be referred for colposcopy.
Recommendations
24. Cytological screening should not be initiated in
women less than 21 years old. (II-2E)
25. If screening is done in a woman less than 21 years
old, and an ASC-US or LSIL result is reported,
cytology should be repeated only per provincial or
territorial guidelines. (III-B)
26. A woman less than 21 years old who has cytology
results of ASC-H, HSIL, and AGC should be
referred for colposcopy. (III-B)
MANAGING HISTOLOGICAL ABNORMALITIES
Once a lesion has been identified on colposcopy and
biopsy has been completed, a decision must be made
regarding management. The aim of treatment is to
remove a potentially precancerous lesion to prevent
development of carcinoma. The initial classification of
cervical intraepithelial neoplasia as CIN 1, 2, or 3 was
proposed by Richart in 1973 and reinforced by the World
Health Organization in 1994.53 The natural history of
dysplastic lesions has been more fully elucidated in
recent years, and this has led pathologists to adopt a
2-tiered cytologic terminology to describe histological
lesions. A recent consensus project led by the College
 Colposcopic Management of Abnormal Cervical Cytology and Histology
Table 2. Evolution of cervical cancer precursors53
Regression, Persistence,
CIN grade % %
CIN 1 57 32
CIN 2 43 35
CIN 3 32 < 56
of American Pathologists and the American Society for
Colposcopy and Cervical Pathology recommended the
following terminology for HPV-associated squamous
lesions: Low-grade squamous intraepithelial lesion
and high-grade squamous intraepithelial lesion, which
may be further classified using the CIN terminology.51
This guideline uses the CIN terminology. The rate
of progression of these dysplastic lesions has been
well reviewed by Ostor52 (Table 2), and over time the
therapeutic approach has been adapted to prevent harm
when lesser CIN grades are unlikely to progress to
invasive cancer.
Treatment modalities include excisional and ablative
approaches (cryotherapy or laser ablation). The favoured
method in Canada is excisional, the loop electrosurgical
excision procedure, which is relatively easy to perform as an
outpatient procedure, although there can be complications.
A recent meta-analysis estimated that after a LEEP
procedure the risk for preterm delivery in a subsequent
pregnancy of less than 32 to 34 weeks gestation, was 1 in
143 treatments.42 The same research group suggested that
a depth threshold of 10 mm is also a variable in reducing
harm. Consequently, if the colposcopist is able to adjust
the procedure to the lesion, negative sequelae in future
pregnancy may be minimized.54
Treatment is tailored to the lesion identified on the cervix
by either removal or ablation of the entire transformation
zone. The International Federation of Cervical Pathology
and Colposcopy has classified the transformation zone into
three categories.17 A type 1 TZ is completely ectocervical
and fully visible. A type 2 TZ is fully visible, has an
endocervical component, and may have an ectocervical
component. A type 3 TZ is predominantly endocervical,
not fully visible, and may have an ectocervical component
(Figure).
Using this classification, ablative methods can be used for
a type 1 or 2 TZ if the following criteria are met: the TZ
must be fully visible; a colposcopically directed diagnostic
biopsy must be taken from the most dysplastic area in the
TZ; there must be no suspicion of invasive disease; there
Progression
Progression to towards invasive
CIN 3, % cancer, %
11 1
22 5
not known > 12
must be no suspicion of glandular disease; there is no
cytological/histological disparity; and the patient has not
had previous treatment.
Cryotherapy is not recommended for treatment of CIN 3.55
If excision with LEEP is used the size of loop electrode
must be adjusted depending on the lesion: a type 2 TZ
requires a larger loop electrode than a type 1 TZ to
ensure the lesion is fully excised. If the lesion is not seen
in its entirety, colposcopy is unsatisfactory and ablative
therapies should not be used.17,56 Care should be taken to
avoid removal of excessive cervical stroma, which would
predispose women to preterm delivery, especially if very
large loops are used or multiple passes taken.
A type 3 TZ with a lesion that extends into the
endocervical canal or a glandular lesion requires a larger or
longer excision for adequate evaluation or treatment. This
document adopted the new the International Federation
of Cervical Pathology and Colposcopy terminology to
identify this procedure as a type 3 excision to avoid the
current confusion in terminology.17 Currently, cone biopsy,
diagnostic excisional procedure, laser excision and LEEP
may be used but have different meanings to individual
colposcopists.56
Managing CIN 1
Evidence from the recent ALTS trial has confirmed
significant interobserver variability in the histological
diagnosis of CIN 1, with the overlap often observed with
benign HPV infection.57 Our current understanding is that
CIN 1 seldom progresses to invasive disease and that it
will regress without treatment within 2 to 5 years in 60%
to 80% of all cases.54,57 Regression rates are even more
pronounced in adolescents, with regression of low-grade
squamous intra-epithelial lesions in up to 91% of cases
over a 3-year period.56 This knowledge has led to a change
in the treatment philosophy for CIN 1.
Conservative management with observation is preferred
for CIN 1. Women should be followed with repeat cytology
testing at 12 months, which can be done by the primary
DECEMBER JOGC DCEMBRE 2012 l 1195
SOGC joint clinical practice guideline

Transformation zone categories

Type I Type II Type III

completely ectocervical has an endocervical has an endocervical

component component

fully visible fully visible not fully visible

small or large may have ectocervical may have ectocervical

ectocervical component component, which may component, which may
be small or large be small or large

care provider; any subsequent management should be Managing CIN 2 or 3 in Women

according to the cytology result. If the patient requires
further colposcopy and the CIN lesion persists for 24
months or longer, treatment is acceptable. If colposcopy
is satisfactory, treatment may be by ablative modalities.
However in an adherent patient, longer follow-up is
possible, especially in women who have not completed
childbearing.
The exception to a conservative approach occurs when a
diagnosis of CIN 1 is preceded by HSIL or AGC cytology.
In these situations, histological findings have not adequately
explained the abnormal cytology. If specimens are available
the cytology and histology should be reviewed and if the
discrepancy is confirmed an excisional procedure may be
considered.
Recommendations
27. The preferred option for biopsy-proven CIN 1 is
observation with repeat assessment at 12 months
with cytology testing. (Colposcopy at 12 months
is an acceptable option.) Management should be
according to the cytology result. (II-1B)
28. In the case of a patient with biopsy-proven CIN 1
after HSIL or AGC, cytology and histology should
be reviewed, where available. If a discrepancy
remains, then an excisional biopsy may be
considered. (III-B)
25 Years Old and Over
Pathologically confirmed high-grade dysplasia includes
CIN 2 and CIN 3, which are treated in the same fashion
in most jurisdictions.7,58-62 There are, however, differences
in the rates of regression. The seminal review by Ostor
showed that CIN 2 regressed in 43% of cases and
progressed to CIN 3+ in 27%.52 This compares with
regression of 33%, persistence of 52%, and progression
to invasion in at least 12% of CIN 3 cases57 (Table 2). The
true malignant potential of CIN 3 has been demonstrated
in New Zealand by long-term follow-up of CIN 3 that was
not treated. This showed that the invasive risk in untreated
CIN 3 is 31% over 30 years. The study also noted that
patients with documented persistent CIN 3 for 2 years had
a 50% risk of subsequently developing invasive disease.63
For these reasons, most women with CIN 2 or 3 should be
treated. Women who are younger or pregnant are managed
as outlined elsewhere in this document. If colposcopy is
satisfactory, i.e., a type 1 or 2 TZ, excision and ablative therapy
are both acceptable; however, an excisional procedure
is preferred for the treatment of CIN 3. If CIN 2 or 3 is
identified and colposcopy is unsatisfactory, an excisional
procedure should be performed. Women are at increased risk
of persistent dysplasia if at treatment margins are positive
for CIN, or the ECC (if done) is positive. In a meta-analysis
of excisional treatment, the risk of post-treatment disease

1196 l DECEMBER JOGC DCEMBRE 2012

 Colposcopic Management of Abnormal Cervical Cytology and Histology
was 18% for incomplete excision and 3% for complete
excision.64 If the deep margins are involved, consideration
should be given to repeat excision. Most women should
have colposcopy repeated at 6 months.65 Hysterectomy is
not recommended as initial therapy for CIN 2 or 3 but may
be performed for women with persistent CIN.
Recommendations
29. CIN 2 or 3 should be treated. Excisional
procedures are preferred for CIN 3. (II-1A)
30. Women who have positive margins should have
follow-up with colposcopy and directed biopsies
and/or endocervical curettage. Treatment for
recurrent or persistent CIN 2 or 3 should be by
excision. (II-1B)
Managing CIN 2 or 3 in Women
Less Than 25 Years Old
As discussed earlier there is little evidence to justify
routine screening in the adolescent patient. If, however,
Pap screening is completed, these patients may be referred
for colposcopy. Management must be modified to prevent
harm. Recent evidence suggests that regression of CIN 2
in this population occurs at a rate similar to CIN 1.10,40,66,67
The evidence suggests that CIN 2 in the adolescent can
be observed with repeat colposcopy and cytology every
6 months for up to 24 months. If dysplasia persists, the
patient should be treated, with either ablative methods or
LEEP. This is conditional on a satisfactory colposcopy.
If colposcopy is unsatisfactory, treatment should consist
of an excisional procedure. A recent study of regression
rates of CIN 2 in women less than 25 years old (most
of whom were 20 to 25 years old) found that the overall
regression rate over a median of 8 months was 62%. This
suggests that observation may be reasonable in women
less than 25 years old.18 In some centres, high-grade
histology is designated as HSIL, i.e., CIN terminology
is not used. If the biopsy specimen is reported as HSIL
in an adolescent woman we recommend a review of the
histology using CIN terminology as suggested by the
College of American Pathologists/American Society
of Colposcopy and Cervical Pathology consensus.
If specimen is reclassified as CIN 3, treatment by an
excisional method is preferred.
Recommendations
31. The pathologist should be asked to clarify whether
the lesion is CIN 2 or CIN 3. (III-B)
32. CIN 2 in women less than 25 years old should be
observed with colposcopy at 6-month intervals
for up to 24 months before treatment is
considered. (II-2B)
33. CIN 3 in women less than 25 years old should be
treated. (III-B)
Managing Adenocarcinoma in Situ
In Canada the ratio of adenocarcinoma to squamous
carcinoma of the cervix is increasing: adenocarcinoma
accounts for 20% to 25% of all cervical cancer.68 This is
largely because widespread availability of screening by Pap
smears over several decades has led to a significant decrease
in squamous cell cancers. Nevertheless, implementation of
cytology quality assurance initiatives in recent years has been
associated with a decrease in adenocarcinoma of the cervix.
In contrast, diagnosis of premalignant adenocarcinoma in
situ occurs at a ratio of 1:50 when compared with severe
squamous dysplasia.69 Consequently a colposcopist will not
often see AIS, and the treatment remains controversial.
Colposcopic features can be difficult to identify, and lesions
often extend high into the canal.70 Bertrand and colleagues
showed that in 78% of cases the highest lesion in the canal
was less than 20mm from the exocervix and none were
higher than 29.9mm.71 After a diagnosis of adenocarcinoma
in situ, made by punch biopsy or endocervical curettage, a
diagnostic excisional procedure, or type 3 TZ excision should
be performed. Margin status is an important predictor of
residual disease, and thus the method chosen for treatment
must preserve the ability to assess the endocervical margin.
A recent meta-analysis of 33 studies showed that the risk of
residual disease was 2.6% with negative margins and 19.4%
with positive margins. Invasive carcinoma was also more
frequently associated with positive margins (5.2%) than with
negative margins (0.1%).72 Thus, if margins are positive, a
second excision is required.
If AIS is diagnosed after a LEEP procedure is completed
(because of a CIN finding), the margins need to be carefully
examined. If the AIS is small and margins are clear, there
is no need to perform an excisional procedure unless
childbearing is complete, when hysterectomy should be
considered.73 If fertility is not an issue or negative margins
cannot be achieved, a hysterectomy is recommended.72
After treatment for AIS, if the woman wishes to preserve
her fertility, she can be closely observed in the colposcopy
clinic. She should be seen for colposcopy, ECC, and
cytology testing every 6 to 12 months, for at least 5 years.
HR-HPV testing can be used to reassure the patient.
Thereafter the patient should have annual cytology testing.
Recommendations
34. If AIS is diagnosed, treatment needs to be
a diagnostic excisional procedure, or type 3
transformation zone excision. (II-2A)
DECEMBER JOGC DCEMBRE 2012 l 1197
SOGC joint clinical practice guideline
35. If margins are positive after diagnostic excisional
procedure, a second excisional procedure should
be performed. (II-2A)
36. If after treatment for AIS a woman has
finished childbearing, a hysterectomy should
be considered. (III-B)
37. If AIS is diagnosed after LEEP is performed
for CIN in a woman who has not completed
her family and margins are negative, it is
unnecessary to perform a further diagnostic
excisional procedure. (II-2E)
Managing Histological Abnormalities
During Pregnancy
The aim of colposcopy in pregnancy is to rule out a diagnosis
of invasive or micro-invasive carcinoma. If invasive or
micro-invasive carcinoma is diagnosed, these cases should
be promptly referred to a gynaecologic oncologist. If CIN
2 or CIN 3 is diagnosed during pregnancy, the available
evidence would suggest that treatment can be delayed until
after delivery. The risk of progression is not affected by the
pregnancy, and the rate of regression to CIN 1 or normal
post pregnancy is between 31% and 47%.74,75
Recommendation
38. If CIN 2 or CIN 3 is suspected or diagnosed
during pregnancy, repeat colposcopy and
treatment should be delayed until 8 to 12 weeks
after delivery. (II-2A)
Follow-up Post Treatment
Once treated for CIN or AIS, a woman remains at risk of
persistence or recurrence and at long-term risk of invasive
carcinoma.62,76,77 Failure rates following treatment for CIN
do not vary significantly with the treatment method used,
and in published series are between 5% and 13%.78,79
The aim of follow-up is to detect persistent or recurrent
dysplasia.
Conventionally in Canada, women are followed after
treatment with colposcopy and cytology testing at 6-month
intervals for 1 to 2 years, and then return to having annual
cytology testing with their primary health care provider. In
recent years the availability of HR-HPV testing has raised
the possibility of its use as follow-up with women who
have tested positive and potentially to detect recurrence
or persistence earlier. Reviews and meta-analyses have
evaluated this approach and demonstrated that HPV testing
may be more sensitive for detecting recurrence.22,8083 It
has been noted that an adequately powered prospective
trial is needed to truly evaluate this issue.83,84 Such a trial is
underway in several Canadian centres.85
1198 l DECEMBER JOGC DCEMBRE 2012
Recommendations
Either option is acceptable:
39. Women should be followed with cytology testing
and colposcopy at 6-month intervals for 2 visits.
If both cytology and any biopsies are negative,
they will then return to screening per provincial/
territorial guidelines. (II-2B)
40. HPV testing at 6 months combined with cytology
testing is acceptable. If both are negative, women
may return to screening per provincial/territorial
guidelines. (II-2B)
Managing Histological Abnormalities
in Women at High Risk
Numerous medical conditions and the medications used to
treat them reportedly affect the ability to limit progression
of HPV infection to dysplasia, and hence are associated with
dysplasia. These include transplantation with associated
immunosuppression and medication for conditions such
as Crohns disease, rheumatoid arthritis, diabetes, or HIV
infection, although most available information relates to
transplant and HIV patients. In a review from 1995, 144
women were followed after renal transplant. There was
a 17.5% incidence of dysplasia.86 Similar outcomes were
reported after liver transplant, as well as a 13% incidence
of HSIL.87
The link between cervical cancer and HIV is well
documented. The rate of cervical cancer is up to 4 to 6
times higher in HIV-positive women.88 In recent years
improved survival has been attributed to the availability
of highly active antiretroviral therapy.88 A review of 400
women who were HIV-positive found that HR-HPV
was present in 68% of these women and that 55% had
abnormal Pap smears. Most Pap smear results were low-
grade changes, of which only 4% progressed and 13%
were HSIL.89 In one review from North America the rates
of CIN 2+ with an ASC US/LSIL referral were 13.3% in
HIV-negative women and 15.3% in HIV-positive women.90
There is no good evidence to recommend routine
colposcopy in this group, and they can be screened with
annual Pap smears.91 Women in whom CIN 1 is diagnosed
at colposcopy can be observed and treated for persistent
disease. CIN 2 and CIN 3 need to be treated, and excisional
methods are preferred. Because there is a high rate of
recurrence, a wide excision should be used.92 Highly active
antiretroviral therapy seems to decrease recurrence.
Recommendation
41. Immunocompromised women do not require
screening colposcopy. (II-2D)
 Colposcopic Management of Abnormal Cervical Cytology and Histology
WAIT TIMES FOR COLPOSCOPY
Patients with abnormal screening tests should be seen for
colposcopy within a reasonable time, given the risk of high-
grade changes and psychological stress associated with
an abnormal cytology result.42 The SOGC Statement on
Wait Times in Obstetrics and Gynaecology recommends
colposcopic assessment within 3 weeks for HSIL cytology,
within 6 to 8 weeks for ASC-H or LSIL, and within 6 weeks
for an AGC cytology result.93 These recommendations are
similar to the recommendation of the National Health
Service Cervical Screening Programme in the United
Kingdom, which states that 90% of cases with high-grade
cytology should be seen within 4 weeks, and 90% of all
tests should be seen within 8 weeks of referral.7
The importance of guidelines to direct referral times to
colposcopy was illustrated in an Ontario population-based
review.94 Referrals were reviewed for Pap smear results of
HSIL, AGC, and ASC-H between 2000 and 2006. Women
with HSIL results were seen in colposcopy at a median time
of 67 days, those with AGC at 108 days, and those with
ASC-H at 80 days. Invasive disease of the lower genital tract
was detected in 2.4 % of those with ASC-H, 3% of those
with AGC, and 3.12% of those with HSIL. Unfortunately
in this population there was a 26% loss to follow-up (i.e.,
women who did not have colposcopy within 24 months).
Recommendations
42. Women with ASC-H or AGC should be seen in a
colposcopy clinic within 6 weeks of referral. (III-C)
43. Women with HSIL should ideally be seen in a
colposcopy clinic within 4 weeks of referral. (III-C)
44. Women with a Pap smear suggestive of carcinoma
should be seen in a colposcopy clinic within 2
weeks of referral. (III-C)
45. All other women with abnormal results should
be seen in a colposcopy clinic within 12 weeks of
referral. (III-C)
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